Nerve damage: Another rare occurrence is damage to surrounding nerves when performing initial puncture or post-procedural compression. The incidence of nerve damage is <0.5%, and symptoms include numbness and tingling at the access site, along with limb weakness. Treatment involves symptomatic management and physical therapy. Nerve damage may also arise secondary to nerve sheath compression from a hematoma.5,9
Thrombosis of the artery. Arterial thrombosis can occur at the site of sheath entry; however, this can be avoided by administering anticoagulation during the procedure. Classic symptoms include the “5 P’s”: pain, pallor, parasthesia, pulselessness, and paralysis. Treatment depends on clot burden, with small clots potentially dissolving and larger clots requiring possible thrombolysis, embolectomy, or surgery.5,10
Systemic Considerations
Postembolization syndrome: This syndrome is characterized by fever, leukocytosis, and pain; while not a true complication, this issue must be addressed, as it is an expected event in post-procedural care. The reported incidence is as high as 90%-95%, with 81% of patients reporting nausea, vomiting, malaise, and myalgias; 42% experience low-grade fever. Typically, the symptoms peak around five days post-procedure and last about 10 days. Although this syndrome is mostly self-limited, it is important to rule out concurrent infection in patients with prolonged symptoms and/or fever outside of the expected time frame.11
(click for larger image)Table 2. Common post-procedural issues
Delayed hypersensitivity to contrast. Contrast reactions can occur anywhere from one hour to seven days after administration. The most common symptoms are pruritis, maculopapular rash, and urticaria; however, more severe reactions may involve respiratory distress and cardiovascular collapse.
Risk factors for delayed reactions include prior contrast reaction, history of drug allergy, and chronic renal impairment. Ideally, high risk patients should avoid contrast medium, if possible; if contrast is necessary, premedication should be provided.
For treatment of a delayed reaction, use the patient’s symptoms as a guide on how to proceed. If the reaction is mild (pruritis or rash), secure IV access, have oxygen on standby, begin IV fluids, and consider administering diphenhydramine 50 mg IV or PO. Hydrocortisone 200 mg IV can be substituted if the patient has a diphenhydramine allergy. In severe reactions, epinephrine (1:1,000 IM or 1:10,000 IV) should be administered immediately.
Hypersensitivity to embolizing agents. Frequently in chemoembolization, iodized oil is used both as contrast and as an occluding agent. This lipiodol suspension is combined with the chemotherapy drug of choice and injected into the vessel of interest. The most common hypersensitivity reaction experienced with this technique is dyspnea. Patients also can experience pruritis, urticaria, bronchospasm, or altered mental status in lower frequencies.
One study showed a 3.2% occurrence of hypersensitivity to the frequently used combination of lipiodol and cisplatin.12 The most common reactions were dyspnea and urticaria (observed in 57% of patients); bronchospasm, altered mental status, and pruritus were observed in lower frequencies. Treatment involves corticosteroids and antihistamines, with blood pressure support using vasopressors as needed.12
Contrast-induced nephropathy (CIN). CIN is defined as a 25% rise in serum creatinine from baseline after exposure to iodinated contrast agents. Patients particularly at risk for this complication include those with preexisting renal impairment, diabetes mellitus, or acute renal failure due to dehydration. Other risk factors include age, preexisting cardiovascular disease, and hepatic impairment. Prophylactic strategies primarily rely on intravenous hydration prior to exposure. The use of N-acetylcysteine can be considered; however, its effectiveness is controversial and it is not routinely recommended.13,14